Medicare Payment for Mental Health Services Iowa Coalition on Mental Health & Aging Presented by Wisconsin Physicians Service (WPS) Medicare Part B Ellen Berra Provider Outreach & Education October 20, 2009 1 Agenda Resources Medicare Mental Health Care Providers Indications and Limitations of Coverage Type of Treatment Considered for Payment Outpatient Mental Health Limitation 2 Resources The Centers for Medicare & Medicaid Services (CMS) Internet Only Manual (IOM) Publication 100-02, Chapter 15, Section 80.2 – Psychological Tests and Neuropsychological Tests The CMS IOM Publication 100-02, Chapter 15, Section 160 – Clinical Psychologist Services The CMS IOM Publication 100-02, Chapter 15, Section 170 – Clinical Social Workers 3 Resources The CMS IOM Publication 100-03, Chapter 1, Part 2, Section 130 – Mental Health The CMS IOM Publication 100-04, Chapter 12, Section 150 – Clinical Social Workers The CMS IOM Publication 100-04, Chapter 12, Section 160 – Independent Psychologist Services 4 Resources The CMS IOM Publication 100-04, Chapter 12, Section 170 – Clinical Psychologist Services The CMS IOM Publication 100-04, Chapter 12, Section 210 – Outpatient Mental Health Limitation Website address: http://www.cms.hhs.gov/Manuals/IOM/list.asp #TopOfPage 5 Resources Medicare Learning Network (MLN) Matters Special Edition SE0441 Website Address: http://www.cms.hhs.gov/MLNMattersArticles/d ownloads/SE0441.pdf 6 Resources Local Coverage Determination (LCD) L26690 – Psychiatry and Psychological Services, Incident to LCD L26691 – Psychiatric Pharmacotherapy Website address: http://www.wpsmedicare.com/j5macpartb/poli cy/active/local/ Then choose your state 7 Coding Resources American Medical Association (AMA) http://www.ana.assn.org CPT Information Services (CPTIS) 1-800-634-6922 General HCPCS Coding Questions http://www.cms.hhs.gov/medHCPCSGenInfo/ 20_HCPCS_Coding_Questions.asp#TopOfP age 8 Appropriate Providers Services can be provided by: Physician MD or DO Clinical Psychologist (specialty 68) Clinical Social Worker (specialty 80) Independent Psychologist (specialty 62) Nurse Practitioner (specialty 50) Clinical Nurse Specialist (specialty 89) Physician Assistant (specialty 97) 9 Incident to Guidelines Applies to services and supplies provided in the office Includes drugs and biologicals Services can be provided incident to the physician or the non-physician practitioner (NPP) 10 Incident to Guidelines Must be an integral, although incidental part of the provider’s professional service Commonly furnished without charge or included in the provider’s bill Commonly furnished in a provider’s office Furnished under direct supervision 11 Incident to Guidelines Providers must be acting within their scope of practice Legally authorized to practice Claim can be submitted by the supervising physician Must meet the “direct supervision” requirements 12 Non-Physician Practitioner (NPP) Billing Incident to billing Bill under supervising physician’s National Provider Identifier (NPI) Services provided under direct supervision Meet incident to guidelines See established patients Allowed at 100% of the fee schedule Direct/Independent Billing Bill under his/her own NPI Work collaboratively or under general supervision of a MD/DO as required by law See new and established patients Allowed at percentage of Physician Fee Schedule 13 Physician’s office within an Institution Must be confined to a separately identified part of the facility used solely as the physician’s office and cannot be construed to extend throughout the entire institution Services performed outside the “office” areas Subject to the coverage rules outside an office setting Could be subject to facility pricing 14 Covered Services Psychiatric Diagnostic Interviews Psychological/Neuropsychological Testing Psychotherapy Services Therapeutic Activity Programs Pharmacotherapy Other Psychiatric and Psychological Services 15 General Clinical Psychiatric Diagnostic or Evaluative Interview (90801) Covered once at the outset of the illness Patient has a suspected or diagnosed psychiatric illness Code is not time related If no mental illness is present use diagnosis code V71.09 Can use Evaluation and Management (E/M) services including consultation codes provided all required elements are present 16 Special Clinical Psychiatric Diagnostic or Evaluative Procedure (90802) Includes the same components and requirements of 90801 Accomplished through the use of inanimate objects, physician aids, and non-verbal communication If patient is incapable of communicating by any means, this code is not appropriate 17 Psychiatric Therapeutic Procedures (90804 – 90829, 90845 – 90865) The appropriate psychotherapy code is chosen on the basis of Type of psychotherapy Place of service Face-to-face time spent with the patient Whether E/M services are furnished on the same day 18 Non-Covered Services There is no Medical Necessity The service provided are Grooming skills Activities of daily living Recreational therapy Social interaction There service is not expected to prevent relapse or hospitalization or to improve or maintain level of functioning 19 Family Psychotherapy (90846, 90487, and 90849) Primary purpose must be treatment of the patient’s condition Efforts are for benefit of the patient, not assisting the family members in understanding the patient’s problem 20 Group Psychotherapy (90853, 90857) Must be led by a person who is authorized by State Statute to perform the service Group size should be a maximum of 12 people Medicare coverage does not include socialization, music, recreational activities, art, or motion therapy, etc. 21 Pharmacologic Medication Management (90862) Includes prescribing, monitoring effects, and adjusting dosage Service is in-depth management of potent medications with frequent serious side effects The patient is primarily managed by psychotropic drugs 22 Pharmacologic Medication Management (90862) Cannot by billed by a Clinical Psychologist (CP) or a Clinical Social Worker (CSW) A provider’s scope of practice must authorize him/her to prescribe medication This service is included in E/M and psychotherapy services received on the same day 23 Pharmacologic Medication Management (M0064) Brief office visit for monitoring, or changing drug prescriptions used in mental health treatment Time spent with patient is generally less than 10 minutes This service is included in E/M and psychotherapy services received on the same day 24 Central Nervous System Testing (96101 – 96125) These services are not psychotherapeutic modalities, but instead are diagnostic aids Standardized batteries of test are not considered medically necessary by Medicare Reading of the report is not a separately payable service 25 Central Nervous System Testing (96101 – 96125) The code description shows when time is associated with the procedure Bill one unit of time when 30 minutes to 1 hour is spent in the administration, interpretation and report of the test Bill multiple units for each additional hour Services performed on multiple days are billed on the last date of the service There is no service billable if the time spent is less than 30 minutes 26 Central Nervous System Testing (96101 – 96125) The procedure code indicates who is required to perform the service Physician or psychologist Technician Computer, with qualified health care professional interpretation and report 27 Central Nervous System Testing (96101 – 96125) 96101 should not be paid when billed for the same tests or services performed under codes 96102 or 96103 96118 should not be paid when billed for the same test or services performed under 96119 and 96120 28 Documentation Requirements The patient’s medical record should contain documentation to support the medical necessity for psychiatric services and that psychiatric services were performed Individual psychotherapy CPT codes should only be used when the focus of the treatment involves individual psychotherapy 29 Documentation Requirements The medical record should document: The patient’s capacity to participate in and benefit from the therapy The target systems, Goals of therapy, Methods of monitoring, and Why the chosen therapy is the appropriate treatment modality (either in lieu of, or in addition to, another form of psychiatric treatment) 30 Outpatient Mental Health Payment Limitation The limitation applies to both procedure codes and diagnosis codes in an outpatient setting The limitation can apply to outpatient medical services when the diagnosis code is a mental health diagnosis The limitation is 62.5% of the Medicare Physician Fee Schedule 31 Outpatient Mental Health Payment Limitation Example: Billed amount is $125.00 Fee Schedule allowed amount is $100 Mental Health Allowed amount is 62.5% or $62.50 Medicare pays 80% or $50.00 Patient is responsible for $50.00 Providers should be aware of the assignment agreement and the Limiting Charge 32 Outpatient Mental Health Payment Limitation Payment for psychological and neuropsychological tests are not subject to the outpatient mental health treatment limitation Payment for the initial assessment – procedure codes 90801 and 90802 are not subject to the limitation Payment for a brief office visit to monitor or change drug prescriptions – M0064 – is not subject to the limitation 33 Questions??? 34 Thanks!!! 35